Application for Health Insurance

TM

Your destination for affordable health insurance, including Medi-Cal See Inside

You can get this application in other languages

Covered California is the place where individuals and families can

The state of California created Covered California™ to help you and your family get health insurance.

Español

1-800-300-0213 1-800-300-1533 1-800-652-9528

Use this application to see what insurance choices you qualify for:

1-800-738-9116 1-800-983-8816 Heccrbq

1-800-778-7695 1-800-996-1009 1-800-921-8879 1-800-906-8528

Hmoob

1-800-771-2156 1-800-826-6317

Apply faster through Covered California at CoveredCA.com Or call: 1-800-300-1506 (TTY: 1-888-889-4500) You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m.

get this application in

|

Things to know information

What you need to know when you apply

We keep your information private and secure, as required by law.

Apply faster online When you’re done

results sooner!

CoveredCA.com

–

Covered California

If you don’t have all the information we ask for, sign and send in your application anyway. Do not send your health insurance plan enrollment payment with this application.

Get help with this application

Call our Customer Service Center at 1-800-300-1506

or call 1-800-300-1506

person or call our Customer Service Center at 1-800-300-1506

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

1

Start application here (use blue or black ink only) Tell us about the adult who will be our main contact for this application

Step 1:

(examples: Sr., Jr., III, IV)

Home State

(home address)

If it is not the same Mailing State

(

)

–

Email

Home

Cell

(

)

Home

–

Cell

____________________________________________________________________________________________________________________________________

Yes If yes,

Yes

If yes, If yes, the mother is If no,

Yes _____________________ on

this application ______________________________________________________________________ __________________________________________________________

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Step 2:

Tell us about yourself and your family

Your spouse

–

his or her own

– will need to file

! for each

Person 1

yourself. Suffix (examples: Sr., Jr., III, IV) Female

Self

Single

Divorced

Registered domestic partner Yes

If yes,

____________

______________________________________________________________________________________

Yes If yes, No

not

No

not

________________________________________________________

_ _ _ – _ _ – _ _ _ _

_________________________________________________________

Religious exemption

1-800-300-1506

Person 1

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Step 2:

Person 1

Yes Yes

benefit If yes,

Yes If yes,

______________________

Head of household

on this application

Single

Yes If yes, Yes

Yes Yes not Yes To see if you have satisfactory status, _________________________________________

___________________________________________________________________________

__________________________________________________________________

___________________________________________________________________

______________________________________________________________________________________________________________________________________

Yes

Yes

Yes

Yes Yes

If yes,

Yes Yes Yes

If yes,

Yes

Yes Yes

Japanese Korean

Guamanian or Chamorro

Chinese

Laotian

Samoan

Filipino

Vietnamese

Hmong

(

Yes

If yes, Salvadoran

Guatemalan

__________________________________

______________________________

Person 1

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

4

Step 2:

Person 1 Yes If yes,

No If no, go to other income

__________

JOB 1:

___________

$ __________________________________ __________

JOB 2:

___________

$ __________________________________

JOB 1:

Yes If yes,

No If no, go to other income

$ _______________________________________________________________

How much

JOB 2:

Yes If yes,

No If no, go to other income

$ _______________________________________________________________

How much

Yes If yes, Where does this income come from?

No If no, go to income change

How often do you get paid? (check one)

How much?

__________

___________

$ __________

___________

$

$ _____________________________________________

this

next

$ ___________________________________________

Yes If yes, Type of deduction

No If no, go

How often do you get or pay for this deduction? (check one) __________

How much? ___________

$

Student loan interest

__________

___________

$

Student loan interest

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Person 2

Step 2:

the next person

If you have more than four people

Suffix (examples: Sr., Jr., III, IV)

If it is not the same Home State

(home address)

If it is not the same Mailing State Home

(

)

Cell

Home

(

–

Female

)

Cell

–

Single

Divorced

Registered domestic partner Yes

If yes,

_____________

_________________________________________________________________________________________

Yes If yes,

No If no,

________________________________________________________

_ _ _ – _ _ – _ _ _ _

_________________________________________________________

Religious exemption

Yes

Yes

benefit Yes

If yes,

If yes,

Head of household

Single

Dependent

______________________

on this application

Person 2

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Step 2:

Person 2 Yes

If yes,

Yes

Yes

Yes not Yes To see if this person has satisfactory status, __________________________________________________________________________

__________________________________________________________________________

___________________________________________________________________

__________________________________________________________________

______________________________________________________________________________________________________________________________________

Yes Yes Does this person

Did this person

Yes

Yes Yes

If yes,

Yes Yes Yes

If yes,

Yes Yes Yes

Japanese Korean

Guamanian or Chamorro

Chinese

Laotian

Samoan

Filipino

Vietnamese

Hmong

(

Yes

If yes, Salvadoran

Guatemalan

____________________________

______________________________

Person 2

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Step 2:

Person 2 Yes If yes,

JOB 1: How does this

No If no, go to other income

__________

___________

$ __________________ JOB 2: How does this

__________

___________

$ __________________

JOB 1:

Yes If yes,

No If no, go to other income

$ ___________________________________________________

How much

JOB 2:

Yes If yes,

No If no, go to other income

$ ___________________________________________________

How much

Yes If yes, Where does this income come from?

No If no, go to income change

How often does this person get paid? (check one)

How much?

__________

___________

$ __________

___________

$

this

next

$ ____________________________________

$ ______________________________

Yes If yes, Type of deduction

No If no, go

How often does this person get or pay for this deduction? (check one) __________

How much? ___________

$

Student loan interest

__________

___________

$

Student loan interest

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Step 2:

Person 3

the next person Suffix (examples: Sr., Jr., III, IV)

If it is not the same Home State

(home address)

If it is not the same Mailing State Home

(

)

Cell

Home

(

–

Female

)

Cell

–

Single

Divorced

Registered domestic partner Yes

If yes,

_____________

_________________________________________________________________________________________

Yes If yes,

No If no,

________________________________________________________

_ _ _ – _ _ – _ _ _ _

_________________________________________________________

Religious exemption

Yes

Yes

benefit Yes

If yes,

If yes,

Head of household

Single

Dependent

______________________

on this application

Person 3

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

9

Step 2:

Person 3 Yes

If yes,

Yes

Yes

Yes not Yes To see if this person has satisfactory status, __________________________________________________________________________

__________________________________________________________________________

___________________________________________________________________

__________________________________________________________________

______________________________________________________________________________________________________________________________________

Yes Yes Does this person

Did this person

Yes

Yes Yes

If yes,

Yes Yes Yes

If yes,

Yes Yes Yes

Japanese Korean

Guamanian or Chamorro

Chinese

Laotian

Samoan

Filipino

Vietnamese

Hmong

(

Yes

If yes, Salvadoran

Guatemalan

____________________________

______________________________

Person 3

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Step 2:

Person 3 Yes If yes,

JOB 1: How does this

No If no, go to other income

__________

___________

$ __________________ JOB 2: How does this

__________

___________

$ __________________

JOB 1:

Yes If yes,

No If no, go to other income

$ ___________________________________________________

How much

JOB 2:

Yes If yes,

No If no, go to other income

$ ___________________________________________________

How much

Yes If yes, Where does this income come from?

No If no, go to income change

How often does this person get paid? (check one)

How much?

__________

___________

$ __________

___________

$

this

next

$ ____________________________________

$ ______________________________

Yes If yes, Type of deduction

No If no, go

How often does this person get or pay for this deduction? (check one) __________

How much? ___________

$

Student loan interest

__________

___________

$

Student loan interest

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

11

Step 2:

Person 4

the next person Suffix (examples: Sr., Jr., III, IV)

If it is not the same Home State

(home address)

If it is not the same Mailing State Home

(

)

Cell

Home

(

–

Female

)

Cell

–

Single

Divorced

Registered domestic partner Yes

If yes,

_____________

_________________________________________________________________________________________

Yes If yes,

No If no,

________________________________________________________

_ _ _ – _ _ – _ _ _ _

_________________________________________________________

Religious exemption

Yes

Yes

benefit Yes

If yes,

If yes,

Head of household

Single

Dependent

______________________

on this application

Person 4

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Step 2:

Person 4 Yes

If yes,

Yes

Yes

Yes not Yes To see if this person has satisfactory status, __________________________________________________________________________

__________________________________________________________________________

___________________________________________________________________

__________________________________________________________________

______________________________________________________________________________________________________________________________________

Yes Yes Does this person

Did this person

Yes

Yes Yes

If yes,

Yes Yes Yes

If yes,

Yes Yes Yes

Japanese Korean

Guamanian or Chamorro

Chinese

Laotian

Samoan

Filipino

Vietnamese

Hmong

(

Yes

If yes, Salvadoran

Guatemalan

____________________________

______________________________

Person 4

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Step 2:

Person 4 Yes If yes,

JOB 1: How does this

No If no, go to other income

__________

___________

$ __________________ JOB 2: How does this

__________

___________

$ __________________

JOB 1:

Yes If yes,

No If no, go to other income

$ ___________________________________________________

How much

JOB 2:

Yes If yes,

No If no, go to other income

$ ___________________________________________________

How much

Yes If yes, Where does this income come from?

No If no, go to income change

How often does this person get paid? (check one)

How much?

__________

___________

$ __________

___________

$

this

next

$ ____________________________________

$ ______________________________

Yes If yes, Type of deduction

No If no, go

How often does this person get or pay for this deduction? (check one) __________

How much? ___________

$

Student loan interest

__________

___________

$

Student loan interest

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

14

Step 3:

Please read and sign this application

State

Your signature

Date

For more information or to see Covered California Covered California

For the Department of Health Care Services

If you do not provide it,

Step 3

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Step 3:

Please read and sign this application

at 1-800-300-1506

Covered California at 1-800-300-1506

If someone on the application qualifies for Medi-Cal:

health insurance or legal settlements related to that California at 1-800-300-1506 For parents whose child or children qualify for Medi-Cal:

does not live with the child and does not send support

visiting

1-916-440-7370

Your rights and responsibilities

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Step 3:

Please read and sign this application

Your right to appeal:

Renewal of insurance

1-800-300-1506

OR

1-800-300-1506

Date

Step 3

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Step 3:

Please read and sign this application

Certified Enrollment Counselor

Phillip Daigle

0B03017

___________________________________________________________ Date

Step 4:

Mailing information and checklist

Mail your signed application to:

Did you remember to:

Covered California

Sign this application on page 17

A few more questions 1. Would you like to be considered for all Medi-Cal programs?

Yes

If you check yes

2. Have you had any recent changes in your life that made you want to apply for health insurance? If yes

Loss of health insurance

__________________________________________________

Step 4

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Step 4:

Mailing information and checklist

How did you hear about Covered California? Radio ad

Email

Sign in retail store Certified Enrollment Counselor

Church Government office

_____________________________________________

Need more information about other programs?

1-877-847-3663

CalFresh www.calfresh.ca.gov CalWORKs

Access for Infants and Mothers (AIM)

Family Planning, Access, Care, Treatment (Family PACT)

Child Health and Disability Prevention (CHDP)

In-Home Supportive Services Program (IHSS) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Women, Infants, and Children (WIC)

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

19

Attachment A:

For American Indians or Alaska Natives

Complete this if you or a family member is American Indian or Alaska Native.

Person 1:

(examples: Sr., Jr., III, IV)

Yes If yes,

_______________________________________________________________________________

__________________________________________________

Yes If no, Yes Yes If yes, No If no,

$ _________________________________

_______________________________________________________

$ _________________________________

_______________________________________________________

$ _________________________________

_______________________________________________________

Person 2:

(examples: Sr., Jr., III, IV)

Yes If yes,

_______________________________________________________________________________

__________________________________________________

Yes If no, Yes Yes If yes, No If no,

$ _________________________________

_______________________________________________________

$ _________________________________

_______________________________________________________

$ _________________________________

_______________________________________________________

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Attachment A:

For American Indians or Alaska Natives

Person 3:

(examples: Sr., Jr., III, IV)

Yes If yes,

_______________________________________________________________________________

__________________________________________________

Yes If no, Yes Yes If yes, No If no,

$ _________________________________

_______________________________________________________

$ _________________________________

_______________________________________________________

$ _________________________________

_______________________________________________________

Person 4:

(examples: Sr., Jr., III, IV)

Yes If yes,

_______________________________________________________________________________

__________________________________________________

Yes If no, Yes Yes If yes, No If no,

$ _________________________________

_______________________________________________________

$ _________________________________

_______________________________________________________

$ _________________________________

_______________________________________________________

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Attachment B:

Tell us about your family’s health insurance

Yes If yes, No If no,

Name Person 1:

What type? _______________________________________________________________________________

Retiree health plan Yes

Person 2:

_______________________________________________________________________________

Retiree health plan Yes

Person 3:

_______________________________________________________________________________

Retiree health plan Yes

Person 4:

_______________________________________________________________________________

Retiree health plan Yes

Attachment B

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Attachment B:

Tell us about your family's health insurance

only

not are examples

Yes If yes, No If no, How much does this person pay in monthly premiums?

Name (for example, Jr., Sr., III, IV)

Employer name

This person:

Does this health plan meet the minimum value standard*?

Person 1:

____________________________

Yes

$

Person 2:

____________________________

Yes

$

Person 3:

____________________________

Yes

$

Person 4:

____________________________

Yes

$

premiums for that plan

$ _______________________

______________________________________ the

.* Date of change __________________________________

*

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Attachment C:

Employer Insurance Form TM

This form is only necessary for those who qualify for health insurance through a job.

1-800-300-1506

Employee:

_ _ _ – _ _ – _ _ _ _ Note for employer:

Employer name:

_ _ – _ _ _ _ _ _ _

State

Email address

____________________________________________

premiums for the

*

$ ________________

_____________________________________

__________________________________________________________________________________________________________

*

_______________________________________

premiums for that plan

$ ______________________

_____________________________________ meets the

* Date of change _________________________________

*

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Attachment D:

visit

Choose your pediatric dental plan and your health insurance plan

or call 1-800-300-1506

1-800-430-4263

Name

Coverage level

Pediatric dental plan name

Child 1:

High Low

Child 2:

High Low

Child 3:

High Low

Child 4:

High Low

Plan type

Covered California plans Name

(for example, Jr., Sr., III, IV)

Health plan name

Metal number

Metal tier

Person 1:

Plan type

Gold Silver

Person 2:

Gold Silver

Person 3:

Gold Silver

Person 4:

Gold Silver

Attachment D

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Attachment D:

Choose your Covered California plans

Agreement for Binding Arbitration

CoveredCA.com 1-800-300-1506

all Signature of Person 1

Date

Signature of Person 2

Date

Signature of Person 3

Date

Signature of Person 4

Date

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Attachment E:

Step 2 references

Immigration status

Self-employment

Use this list for "Applying for health insurance"

Use this list for "Are you self-employed?"

qualify for health insurance

may

Depreciation Refugee Legal and professional services

Repairs and maintenance

Examples of other income Use this list for "Do you have other income?" Deferred action status Retirement or pension income Granted withholding of deportation or withholding Capital gains Farming or fishing income Court awards

visa petition

Deductions Use this list for "Do you have deductions?" Student loan interest deduction Educator expenses

Health savings account deduction Domestic production activities deduction

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Attachment F:

Federal Poverty Guidelines

1

4

You may be eligilble for Medi-Cal.

¿Preguntas? CCFRM604 (11/13) EN

You may be eligible for insurance with financial help through Covered California.

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Frequently Asked Questions (FAQ) Getting help through Covered California 1. What is Covered California?

6. What health insurance is offered through Covered California? cover you

cannot refuse to

Covered California offers four groups of private health

2. What is Medi-Cal?

3. What is Access for Infants and Mothers (AIM)?

and

1-800-300-1506

4. How can Covered California help me?

7. Can I get health insurance through Covered California? Covered California if he or she is a state resident and

or for financial help that can lower the cost of premiums

8. How much does it cost? 5. Can I get health insurance even if my income is too high? health insurance through Covered California regardless

Frequently Asked Questions

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Frequently Asked Questions Getting help through Covered California

13. Do I need health insurance now that health reform has started?

9. Should I include my first premium payment with this application?

10. How do I apply?

Online: Visit

By phone: Call Covered California at 1-800-300-1506

By fax: By mail: Covered California

In person:

office or Covered California

or call

1-800-300-1506

14. I don’t have all the information I need to answer the questions on the application. What should I do?

11. I am currently enrolled in Medi-Cal. Can I get health insurance through Covered California? us at 1-800-300-1506

15. What will happen after I apply? 12. What if I already have health insurance?

1-800-300-1506

Frequently Asked Questions

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Frequently Asked Questions Getting help through Covered California

Financial assistance

16. Can I get help with my application or with choosing a plan?

18. I don't make a lot of money. What programs are available to help me get health insurance?

A. Assistance with monthly premiums.

Online: Visit

By phone: Call Covered California at 1-800-300-1506

B. Medi-Cal:

In person:

or call

1-800-300-1506

19. If my income changes, will my premium assistance change immediately?

17. How can I choose a health insurance plan?

Covered California will offer choices of private health

20. If my income changes, how will the change affect me when I file my taxes? California that affect the amount of premium

Or,

1-800-430-4263

Frequently Asked Questions

Need help? CCFRM604 (11/13) EN

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Frequently Asked Questions Financial assistance 21. What if I didn’t file taxes last year?

22. What if my income changes after I apply?

26. Will I be able to use my new Covered California health insurance plan right away?

27. What do you mean by “disability”?

Other questions 23. Does everyone on the application have to be a U.S. citizen or U.S. national? You do not

24. Will my family and I qualify for the same program?

25. This application asks for a lot of personal information. Will Covered California share my personal and financial information?

28. I have a pre-existing condition or disability. Can I get health insurance through Covered California?

29. I just found out I am pregnant. Can I apply for health insurance that will cover me during my pregnancy?

Frequently Asked Questions

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Frequently Asked Questions Other questions 30. I just had a new baby. What should I do about health insurance?

35. Where can I get information about becoming registered to vote?

36. I am an American Indian or an Alaska Native. How can Covered California help me?

1-800-433-2611

31. Will I qualify for health insurance if I am not a citizen or do not have satisfactory immigration status?

need to send

37. What if I don’t agree with the decision Covered California makes?

information with other government agencies to see

32. Were you in foster care on your 18th birthday?

Online: Visit By phone: Call Covered California at 1-800-300-1506

By fax: Fax the appeal to 1-888-329-3700 By mail:

33. What constitutes a one-time payment?

In person:

For a list of Certified Enrollment Counselors and

34. What does “self-employed” mean?

Need help? CCFRM604 (11/13) EN

or call 1-800-300-1506

Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

Extra help may be available CalFresh to help!

1-877-847-3663 or visit

Welltopia by DHCS

Cool videos

CalFresh

Earned Income Tax Credit (EITC)

Child Tax Credit

¿Preguntas? CCFRM604 (11/13) EN

Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

Getting help in other languages You can get help with this application in other languages. Call 1-800-300-1506.